J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.51.8.1022 on 1 August 1988. Downloaded from Journal of Neurology, Neurosurgery, and PsychiatryI 1988;51:1022-1031 Limb pain in migraine and cluster headache R J GUILOFF, M FRUNS* From the Department of Neurology, Westminster Hospital, Charing Cross and Westminster Medical School, London, UK SUMMARY Upper limb pain occurred in close temporal association with attacks of migraine, cluster headache and cluster-migraine in 22 cases. Seven had also lower limb pain. Limb pain was usually ipsilateral to the headache but could alternate sides and behaved like other accepted migraine accompaniments. It was always ipsilateral to the associated paraesthesiae/numbness (9 cases) and weakness (6 cases). The distribution and restricted localisations of limb pain were similar to those of the sensory symptoms and could not be accounted for by primary dysfunction of the peripheral or autonomic nervous systems. A central origin for limb pain is postulated. A temporary dys- function in the somatosensory cortex, and/or its thalamic connections, during migraine or cluster headache attacks, might mediate such pain in a number of patients. "The particular form and character of the paroxysm Wakefield reported a patient with migraine and pain will be determined chiefly by the extent and anatomical and weakness in the leg.20 Radiation of chest pain to localisation of the disturbance in each case ... " the arm has been described in "precordial or cardiac Protected by copyright. (Liveing, 1873) migraine".2' Sjaastad and Dale reported spread to the ipsilateral shoulder and arms in patients with Liveing referred to upper and lower limb pain in asso- "chronic paroxysmal hemicrania".2223 Olesen et al. ciation with paraesthesiae in migraine.1 Gowers referred to a patient with migraine and unexplained stated that migraine pain may radiate from the side of attacks of upper limb pain.24 the head to the neck and arm.2 Jeliffe described a Weakness or visual and sensory phenomena are patient with right sided migraine and ipsilateral pain accepted focal symptoms of migraine but limb pain is and numbness in the arm and numbness and weakness not included in standard descriptions.2528 Since in the leg.3 Other cases with upper limb pain were upper limb pain in "cervical migraine" was inter- reported by Sluder,4- 8 Cushing,9 Harris,10 Vail, 1 112 preted as secondary to cervical spine trauma,29 30 no Glaser,"3 Frazier, 14 and Brunelli. 5 Cases with pain in critical analysis of a series of such cases has been the lower limb were reported by Gowers,2 Sluder,s reported, nor has the pain mechanism been consid- and Brunelli.'5 ered in terms of recent anatomical and physiological There are few reports in the more recent literature. data. Montgomery and King'6 described a case of hemi- We report 22 cases with unilateral, sometimes alter- plegic migraine with paroxysmal shoulder-hand syn- nating, limb pain as a prominent complaint associated http://jnnp.bmj.com/ drome. Wolff accepted radiation to the arm in with "vascular headache of migraine type".3' The "cephalalgias and atypical neuralgias of the face and features of the pain and its temporal relationship with head", regarded the mechanisms of pain as similar to the headache suggest that it is either part of the head- migraine and stated that it could be improved by ache episode or that it behaves like other accepted ergotamine tartrate. 17 Sacks described a woman with accompaniments of "migrainous headache". Limb episodes of migraine and pain in the hands. 18 pain does not respect current classification Sutherland and Eadie referred to extension of pain to boundaries32 and has been seen in association with the ipsilateral arm in a case of cluster headache.'9 common and classical migraine, cluster headache and on September 30, 2021 by guest. cluster-migraine. The complaint is benign and has Address for reprint requests: Dr R J Guiloff, Westminster Hospital, occurred over many years without sequelae. A central 17 Page Street, London SWIP 2AP, UK origin for limb pain and implications for the mech- *British Council Scholar. Present address: Institute of Neurology, anism of the headache will also be discussed. Queen Square, London WC I N 3BG, UK. Methods and material Received 25 August 1987 and in revised form 26 January 1988. Accepted II April 1988 The diagnosis of migraine and related "vascular" headaches 1022 J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.51.8.1022 on 1 August 1988. Downloaded from Limb pain in migraine and cluster headache 1023 is clinical. When relating a particular symptom to the condi- alternate between sides. It started either with or fol- tion, it is necessary to describe cases of headache acceptable lowing the headache, but could also occur indepen- to many neurologists as examples of migraine, cluster head- dently, in isolation. Paraesthesiae and/or numbness ache and cluster-migraine and to show that a pattern of and/or weakness were often associated ipsilaterally to association between the headache and that symptom exists, both limb pain and headache. The commonest trig- in the absence of other detectable known mechanisms or gering or exacerbating factor for limb pain was limb causes for it. use or movement. Table I summarises all cases. Illus- Patients were selected prospectively from all new patients referred to, and examined by, the same neurologist (RJG), by trative cases are described below. the coexistence of limb pain and headache with a temporal profile suggestive of an association between the two (see Analysis of clinical data below). When accepting a diagnosis of migraine, cluster Limb pain. Limb or body pain was the main, or a headache or cluster-migraine, the features of the headache prominent, complaint in 20 cases and one, or the only, and associated symptoms, excluding limb pain, were consid- reason for referral in 16. It did not precede the head- ered (see below). ache in any case and was concomitant with the latter The headache fitted the definitions of migraine proposed in 15 patients. Six cases timed limb pain to a "few i the Ad Hoc Committee for the Classification of minutes", 5 min, 30 min, I h and 2 h after the onset of ,teadaches3" and by Lance27 or that of cluster headache pain started after the headache proposed by the Research Group on Headache of the World headache. Limb Federation of Neurology.33 We accepted cluster attacks episode in 1 case. lasting longer than 2 hours as, in our experience, this may occur. Others have described single attacks lasting 1-2 Case I Common migraine and concomitant neck and arm days. 19 34 Classical migraine is used as in Rose's pain. A 19 year old girl presented with a I month history of classification.32 including focal visual, motor and sensory frequent episodes of throbbing pain in the left temple, above symptoms and basilar migraine. Cluster-migraine35 is used the left ear, left side of the neck and left arm, lasting a few for cluster headache associated with paraesthesiae, weak- hours and sometimes associated with nausea. She had been ness, visual phenomena or because the headache could be on a contraceptive pill for 7 months. A sister had headaches. Protected by copyright. bilateral. Classification of headache was made for those that Following propanolol she reported a reduction in the fre- had occurred previously, and for those at presentation and quency of her headaches. during follow-up, with and without limb pain (table 1). Isolated independent episodes of limb or body pain A temporal profile suggestive of an association between were reported by 11 patients. In nine of them the pain as occurrence of one headache and limb pain was defined the affected the same part of the limb to the one involved or more episodes of such pain immediately preceding or following the onset of headache, present during it, or shortly during a headache episode. One reported pain in the after it. Good evidence of response to a drug was judged fingers with headache and pain in the ulnar side of the from recurrence on drug withdrawal or reduction in dose. forearm and dorsum of the wrist in isolation. Another Partial response was scored when chance or placebo effect had pain in the shoulder with headache and pain in the could not be excluded. ventral aspect of the wrist in isolation. Twenty-two consecutive cases were collected between I January 1983 and 30 June 1986. They were seen at two Case 13 Cluster headache with associated or isolated central London teaching hospitals serving a local population ipsilateral chest and upper and lower limb pain. This 54 year of 125,000, as well as commuters and specialist referrals. old woman had had episodes of left-sided throbbing head- Thirteen lived locally, nine outside the district. There were 19 ache and throbbing pain in the left side of the chest radiating females and three males. One patient was lost to follow-up. to the left shoulder and arm and left hip and thigh lasting In the remainder, median follow up was 9 months; 10 cases 1-3 h for at least 10 yr. They occurred daily in bouts lasting http://jnnp.bmj.com/ (47%) were followed for one or more years (table 1). about 6 wk with pain free intervals of up to 2 wk. A recent bout had lasted for 3 months. Often they were associated Results with a feeling of a blocked nose. On occasions there was only chest and limb pain during the bout, but when she had Most patients with limb pain were female. young and headache she had also chest and limb pain for the same of time.